This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:

CASE DISCUSSION

A 56 year old female patient came to the op with complaints of shortness of breath since 2 months

HISTORY OF PRESENTING ILLNESS

Patient was apparently alright 2months ago then she developed Shortness of Breath which was insidious in onset , aggravated on exertion like walking . Relieved on taking rest , associated with seasonal variation , not associated with diurnal variation . 

No orthopnea , pedal edema , Paroxysmal nocturnal dispneoa , decreased urine output .

No h/o fever , vomitings, loose stools , sore throat , chest pain , palpitations , blurring of vision 

She is a k/c/o HTN since 9years 

K/c/o Asthma since 10years and on Formeterol

K/c/o CVA (Acute infarct in left semi ovale ) 1 year back

She is a k/c/o psychiatric disorder in which she talks to herself and laughs at herself and she is on Amisulpride 

ON EXAMINATION

Pt is Concious, Coherent, co-operative 

No Pallor , Icterus , Clubbing, Cyanosis Lymphadenopathy, pedal oedema

VITALS:

 Temp: Afebrile

Pulse : 85/min irregularly irregular

Resp rate : 22/min

Bp: 150/90 mm hg

SYSTEMIC EXAMINATION

CVS : S1,S2 heard ,no murmurs 

CNS : No focal neurological deficits

RS: decreased air entry on right side

PA: soft, non tender
















Provisional diagnosis :

Paroxysmal Atrial fibrillation with k/c/o CVA - Right sided hemiparesis with acute infarct in the left semi ovale 

Treatment given :

O2 inhalation if saturation <90@ RA

TAB. ECOSPIRIN -AV 75/10mg OD

INJ. LASIX 40MG/IV/BD

INJ.PAN 40mg OD IV/OD

NEBULIZATION WITH BUDICORT 2 RESPULES AND IPRAVENT 2 RESPULES 6TH HRLY

TAB. AMIODARONE 100MG /OD 

TAB. MONTELEUKAST-LC H/S

TAB. RAMIPRIL 5MG /OD 

SYP. CREMAFFIN 15ML /TID

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